10 WHITE STREET SYSTEM PUMPING RECORD 12-23-19 '`. Commonwealth of Massachusetts
I City/Town of- e
_ i System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, !
use only the tab
key to move your Address
cursor-do not �� �� 0 f q 70
use the return key. City/Town State Zip Code !^
2. System Owner::
r �
Name
Address(if different from location)
Cityrrown State Zip Code
�73-7qo
Telephone Number
B. Pumping Record
1. Date of Pumping oaten ( 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By*
Name Vehicle License Number
—---
Company
-
7 Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt) yaqll.44��
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